Financial Affidavit And Application {SCA-C-M201}

SCA-C&M201: Financial Affidavit and Application Revision Date: 12/14/2016; WVSCA Approved Date: 03/23/2011; Docket Code(s): MCMWFPage 1 of 3 IN THE COURT OF COUNTY, WEST VIRGINIA Plaintiff or Petitionerv. Defendant or Respondent Case No. FINANCIAL AFFIDAVIT AND APPLICATION: ELIGIBILITY FOR WAIVER OF FEES, COSTS, OR SECURITY IN A CIVIL OR DOMESTIC CASE OR FOR COSTS ASSOCIATED WITH REQUIRED POLYGRAPH EXAMINATION OR ELECTRONIC MONITORING1.You will be allowed to file and carry on your civil proceeding without giving security or paying fees or costs thatwould otherwise be required, if the court finds that you meet the official financial guidelines.2.You must complete the affidavit for the court to determine if the costs of either a polygraph examination, requiredby W.Va. Code 247 62-11D-2, or electronic monitoring, required by W.Va. Code 247 62-11D-3, will be paid by thesupervising entity.3.You must file a separate affidavit and application anytime your financial situation no longer meets the officialguidelines or anytime the court orders you to do so.4.You must attach a copy of your most recent salary stub, W-2 form, or other financial documentation (with all socialsecurity numbers and all dates of birth removed [you can black them out]) that verifies your income. Without theattached documentation, your application will be incomplete and not considered.5.At any time you may request or the court may require review of your eligibility for a waiver; and at any time thecourt may require you to pay fees or costs previously waived or to pay future fees or costs.6.When you sign this form, you will have to swear or affirm that you have completely and truthfully provided allinformation sought, to the best of your knowledge and ability. If you knowingly give any incomplete and/or falseinformation, you may be prosecuted for the crime of false swearing.7.The information you give in this form will be confidential only in a domestic violence or a divorce case.8.Except for signatures, all information must be clearly printed.A. Information for the Applicant:B. Information about You and Your Case: 1a. Name: 1c. Address: 1b. Telephone Number: SCA-C&M201: Financial Affidavit and Application Revision Date: 12/14/2016; WVSCA Approved Date: 03/23/2011; Docket Code(s): MCMWFPage 2 of 3 2.Describe what is involved in your case: Case No. . No3a. Do you have a lawyer? Yes 4.Check if seeking waiver for:Cost of required polygraph examination (W.Va. Code 247 62-11D-2); and/orCost of required electronic monitoring (W.Va. Code 247 62-11D-3).b.Have you paid or will you have to pay your lawyer?c.Will you have to pay your lawyer only if you win?NoYes NoYes C. Information about Your Financial Situation:1a. What is your current yearly net (take-home) income from all sources: Employer: $ Second Job: $ Self-Employment: $ Public Assistance: $ Food Stamps: $ Unemployment: $ Benefits: $ Disability Benefits: $ Social Security/SSI: $ Alimony: $ Pensions: $ Rental Income: $ Interest: $ Dividends: $ Annuities: $ Odd Jobs: $ Other: $ (specify): YEARLY TOTAL: $ 1b. If your listed income is zero (0), please explain below and attach some verification (i.e. DHHR or food stamp information):Please remember to attach financial documents which verify this information.2a. List the names and relationships to you of all the persons supported by this income, whether or not they are household members (provided, that these persons can be claimed as dependents on your federal tax return):and/or bonds (liquid assets)? $2b. What is the total number of dependents, including yourself ? . . 3.How much money do you, individually or jointly, have in cash, checking and savings accounts, deposit certificates, SCA-C&M201: Financial Affidavit and Application Revision Date: 12/14/2016; WVSCA Approved Date: 03/23/2011; Docket Code(s): MCMWFPage 3 of 3 4a. List your regular monthly household debt-payment and other expenses: 5a. List all cars, trucks, motorcycles, or recreational vehicles (all-terrain vehicles, motor homes, snowmobiles, boats), including their make, model, and year, that you own, individually or jointly:5b. What is the total value of these items less any amount owed? $6a. List all real estate (houses, lots, land, rental property, other commercial property) that you, individually or jointly, own.7.What would the consequences be for you if a waiver of fees, costs, or security is denied?8.This application consists of three (3) pages andpages of supporting financial documents. By signing my name on this form, I swear to or affirm: (1) the completeness and truthfulness, to the best of my ability and knowledge, of the information I have provided and (2) my belief that I have a right to a waiver.Signature of Affiant-Applicant: Taken, subscribed, and sworn or affirmed before me, by the person whose signature appears above, on this day of , 20, in County, West Virginia.Signature of Notary (Clerk or Deputy Clerk): For Court Use Only Case No. Mortgage/Rent: $ Car Payment: $ Loan Payments: $ Credit Card Payments: $ Other Debt Payments: $ Utilities: $ Cell Phone: $ Food: $ Child Care: $ Child Support: $ Alimony: $ Medical Bills: $ Other Expenses: $ (specify): 4b. What is the total amount of these monthly expenses? $ . . 6b. What is the total value of these items less any amount owed? $ . The affiant's application for a waiver is (clerk: initial one) granted denied.Signature of Clerk or Deputy: Date: